Traditional birth attendants’ knowledge, preventive and management practices for postpartum haemorrhage in Osun State, Southwestern Nigeria

Traditional birth attendants (TBAs) have become an integral part of the workforce providing delivery services in Nigeria due to the limited number of skilled birth attendants and cultural preferences. This study assessed the knowledge, management and preventive practices regarding postpartum haemorrhage (PPH) among TBAs in selected communities in Osun State, Southwest Nigeria. The study employed a descriptive cross-sectional study design and recruited 260 TBAs in four communities in Osun State. Data were collected by means of an adapted semi-structured questionnaire. Data were analysed using SPSS version 23 and summarized using descriptive and inferential statistics (chi-square and logistic regression) with the level of significance set at p < 0.05. The findings indicated that most (71.4%) of the TBAs were cleric, while others were herbalist (28.6%). Although the majority (76.4%) of the TBAs had good knowledge of the causes and warning signs of PPH, a high percentage (69.3%) of TBAs had poor management practices, while 114 (64.1%) TBAs had inadequate preventive practices. Notably, almost none of the participants practised active management of the third stage of labour; the majority of TBAs did not administer any uterotonic drugs to the mother, nor did they deliver the placenta by controlled cord traction. Gender (P = 0.029), educational level (P = 0.035) and average number of births per month (P = 0.001) significantly influenced TBAs’ management practices. Similarly, the TBA type (P < 0.001), average number of births per month (P = 0.003) and experience with formal training (P = 0.005) showed significant associations with TBAs’ preventive practices. Furthermore, TBAs’ preventive practices towards PPH were influenced by the TBA type (OR: 4.23; 95% CI 1.64–10.90). TBA management practices were also influenced by the TBA type (OR: 4.42; 95% CI 2.03–9.61). Traditional birth attendants in this study had poor management and poor preventive practices for postpartum haemorrhage.

www.nature.com/scientificreports/ maternal mortality in developing countries and the main cause of maternal deaths worldwide (approximately 2 one-quarter) 2 . Nearly all deaths resulting from PPH occur within the first 24 h after birth. The majority of these could be avoided through the use of prophylactic uterotonics during the third stage of labour and by timely and appropriate management 2 .
In developing countries where the majority of maternal death occurs, multiple causes include haemorrhage, obstructed labour, sepsis, eclampsia/preeclampsia, anaemia, inadequate human resources for health, delay in seeking care, inadequate equipment, lack of ambulance transportation, and delay in referral services 3,4 . Approximately 94% of all maternal deaths occur in low-and lower-middle-income countries 4 , including Nigeria. Approximately half of these maternal deaths are referred from traditional birth attendants (TBAs) and mission houses 3 . Due to inadequate human resources coupled with a massive brain drain of health care workers in the health sector in low-and lower-middle-income countries 3,5 , there is a massive deficit of human resources for health 5 . Due to this deficit in most developing countries, TBAs remain a major part of maternal and child health care in resource-poor settings such as Nigeria 6 .
A consensus emerged in the late 1990s among leaders in global maternal health that TBAs should no longer be trained in delivery skills and should instead be trained as promoters of facility-based care 7 . However, traditional birth attendants have remained in most developing countries due to their acceptability (cultural, norms, financial and spiritual), accessibility, and availability as well as the poverty level, poor female education and weak female empowerment 7,8 . A TBA, according to the World Health Organization, is "a person who assists a mother during childbirth and who initially acquired her skills by delivering babies herself or through apprenticeship to other traditional birth attendants" 95 .
The topic of this study is largely under researched and poorly understood. However, in developing countries, TBAs continue to play a key role in maternal and child health. If Sustainable Development Goals 3 and 3.1 are to be achieved by 2030 in these parts of the world, the input of TBAs must not be neglected, and the approach should be inclusive and supportive. This study aims to identify the knowledge gap among TBAs for PPH and the preventive practices and management practices for PPH among TBAs. The study also investigates the predictors of good preventive practices and management practices among TBAs.

Methods
Research design. This study employed a descriptive cross-sectional design designed to assess the management and preventive practices of traditional birth attendants regarding postpartum haemorrhage.
Description of study area. The study was carried out in Osun state, south-western Nigeria and it's organized politically into 30 local government areas and three senatorial districts, as illustrated in Fig. 1 10 . Osun   11 . The state health sector came into being during the creation of the state on 27th August 1991 with two (2) agencies, the Ministry of Health and the Hospitals Management Board, as the administrative and supervisory bodies controlling the activities of the sector. Furthermore, the number of health care facilities has increased as follows: 876 primary health care (PHC) facilities, 57 secondary health care facilities, and 2 tertiary health institutions, Obafemi Awolowo University Teaching Hospital Complex (OAUTHC) and Osun State University Teaching Hospital 12 . Maternal mortality remains persistently high in Osun State with no significant improvement; accounting for 32% of all deaths among women of reproductive age 10,13,14 . This menace is largely due to suboptimal uptake and quality of antenatal care, low utilization of TBAs and skilled birth attendants (SBAs) (38%), high rates of home deliveries, poor quality of delivery services, limited access to emergency obstetric care services and adverse reproductive behaviours. TBAs/SBAs have 92% coverage across Osun State 12,15,16 . Baseline information. TBAs are persons (usually women) who assist mothers at childbirth and who initially acquire their skills by delivering babies themselves (self-taught) or by working with other TBAs (apprenticeship) 17 . They are traditional, independent (of the health system), non-formally trained, community-based providers of care during pregnancy, childbirth and the postnatal period 18 . When TBAs receive any form of formal midwifery training, they are referred to as trained TBAs (TTBAs). There are two types of TBAs in Osun State and the country (Nigeria): faith-based and private practitioners. Faith-based TBAs operate 1. in "faith homes", most of which are affiliated with churches and a few with mosques and are often referred to as cleric TBAs and 2. others with traditional healing institutions, who are referred to as herbalist TBAs 19 . TBAs' protocols in Nigeria are prepared and imposed by the National Primary Health Care Development Agency (NPHCDA), an agency under the Ministry of Health. The agency ensures compliance through periodic monitoring by its various arms of the local government primary health care departments (LGPHCDs) 20 .
In Osun State, Nigeria, the Ministry of Health as well as the various LGPHCDs are involved in the training and retraining of TBAs. At the local government level, a training session lasts for 3 weeks, while retraining lasts for a week. A trained TBA is expected to have retraining at least yearly. The training cost is borne by the participants. TBAs are trained in correct knowledge of the function, dosing and timing of administration of misoprostol and oxytocin and the use of the delivery kits. Upon completion of training, each TBA is given a delivery kit, misoprostol, oxytocin, antibiotics, analgesics, Fleet enemas and other drugs. Each local government has a TBA programme officer who coordinates the training programme and supervises their practices. The programme officer in most cases is a chief nursing officer with the local government PHC department. Trained TBAs are registered with the local government and are expected to meet with the programme officer on a monthly basis for a review of their activities. There is no precise figure for the total number of registered TBAs in the state due to poor data management, a common problem that afflicts all parastatals in the country 10 Ilesa is a town in Osun State in southwest Nigeria as well as the name of a historic kingdom centred in that city (also known as Ijesha). Its geographical coordinates are 7° 37′ 0″ N, 4° 44′ 0″ E. It lies in the Yoruba Hills at the intersection of roads from Ile-Ife, Osogbo, and Akure. It falls under the Ijesa South Federal Constituency and Osun East Senatorial District.
Osogbo: Also spelled Oshogbo, this town is the capital of Osun State in southwestern Nigeria. It has a population of 395,500 people and is bordered by Ikirun, Ilesa Ede, Egbedore, and Iragbiji. It is easily accessible from anywhere in the state, with coordinates of 7°46′ N 4°34′ E and a total landmass of 2875 km 2 . The city had a population of 156,694 people according to the 2006 census, which increased to 772,000 in 2023 11 . It falls under the Osogbo Federal Constituency and Osun Central Senatorial District.
Target population. The study populations were traditional birth attendants (TBAs) who were registered and who had structures and birth centres within Osun State. A total of 426 TBA centres were estimated to be within these locations, i.e., the number of TBAs with centres.
Inclusion criteria. The inclusion criteria for this study were TBAs within Gbogan, Ilesa, Osogbo and Ile-Ife who had physical structures within the area for delivery (because the study focused on the prevention and management of postpartum haemorrhage) and indicated willingness to participate in the study. A community mapping exercise was conducted to identify and enumerate all TBA centres across the four locations of Ilesa, Osogbo, Gbongan and Ile-Ife. Only those centres that met the criteria and were willing to participate in the study were recruited into the study. Proportionate allocation of Traditional Birth Attendants Centres in selected areas is shown below.

Definition of variables.
The following operational terms were adopted in the study and form the basis on which the instrument was developed: • Knowledge: facts or information on postpartum haemorrhage acquired by traditional birth attendants through experience or education. • Practices: actual application or use of an idea or belief that promotes or aids exclusive breastfeeding among nursing mothers. • Preventive practice: practice intended to protect, promote or maintain the health and well-being of mothers and help to prevent disability or death arising from postpartum haemorrhage. • Postpartum haemorrhage: severe vaginal bleeding after childbirth usually caused by loss of tone in the uterine muscles, a bleeding disorder or the placenta failing to come out completely or tearing. www.nature.com/scientificreports/ Instrument for quantitative data collection. A semistructured, self-administered questionnaire was used for data collection in this study. The questionnaires were adapted by the authors from other studies 21,23 . The components of the questionnaire were categorized into five (5) segments: a) Section A contained questions that assessed the sociodemographic information of the respondents (TBAs), including age at last birthday, gender, educational level, ethnicity, religion, year of practice, year of establishment, and mode of training. b) Section B contained questions to determine the participants' knowledge of the causes and warning signs of PPH. Knowledge of PPH was scored based on ten (10) items. TBA knowledge was categorized into poor or good knowledge. Every correct answer, that is, a 'yes' , was scored 1 point for a total of 10 points for knowledge of the causes and warning signs of postpartum haemorrhage. The 50th percentile (the mean) was used as the baseline for scoring poor/good knowledge. c) Section C contained questions to assess the management practices of TBAs towards PPH. Management based on the existing protocol was scored based on ten (10) items. The existing protocols were categorized into poor and good management practices. ' Always' and 'sometimes' responses were scored 1 point for a total of 10 points, while 'rarely' and 'never' responses were scored '0' points for management practices of postpartum haemorrhage. The 50th percentile was used as the baseline for scoring poor/good management practices. A four (4) point Likert scale was adopted in this study to eliminate neutrality. Also, it is best use in situations in which a specific user opinion is essential 24 . d) Section D assessed the preventive practices of TBAs against PPH. Preventive practices were scored based on nine (9) items. Responses were categorized into inadequate and adequate preventive practices. Every correct answer, that is, a 'yes' response, was scored 1 point for a total of 9 points for adequate preventive practices for postpartum haemorrhage. The 50th percentile was used as the baseline for scoring inadequate/adequate preventive practices. e) Section E assessed the factors influencing the management practices of PPH among TBAs.
Validity and reliability of the instrument. This study ensured external and content validity. The researchers and two other experts in the field of study closely examined the items in the questionnaire to ensure that they could accurately measure the intended variables. A pretest was conducted among TBAs in other locations outside the study settings (Ede and Ipetumodu). Relevant adjustments were made before the final administration of the questionnaire to the research population. The test-retest method was used to assess the reliability of the instrument. The internal consistency of the items showed an intraclass correlation coefficient of 0.8.
Data collection procedure. The period for data collection was twelve (12) weeks from April to June 2022.
Data were collected through self-administration of the questionnaires. The questionnaire was translated to Yoruba and was as simple and clear as possible with the targeted sections and questions. The researcher visited only TBA centres that conducted deliveries. Respondents were met at their respective centres and informed of the study. Each participant was equally informed about the purpose of the study, and guidelines for the completion of the questionnaire were explained to the participants, who were asked to tick where appropriate. The data collection lasted for 3 months.
Data management and statistical analyses. After data collection, the questionnaires were properly checked for completeness. The collected data were entered manually and analysed using IBM Statistical Product and Service Solutions version 24 (SPSS, Inc. USA). Frequency tables, percentages, charts and descriptive statistics (mean and standard deviation) were used to report the results.
Inferential statistics chi-square (χ2) was used to test for associations between the independent variables (respondents' sociodemographic variables) and outcome variables (management and preventive practices). Additionally, a multiple logistic regression model was used to assess predictors of the preventive and management practices of TBAs towards PPH. Statistical significance was one-tailed, with a p value less than 0.05 for all inferential analyses.
Ethical considerations. The study was conducted in conformity with the Declaration of Helsinki, and the protocol was approved and ethical clearance was obtained from the Osun State Health Research Ethical Committee (PROTOCOL NUMBER: OSHREC/PRS/569 T/261). Informed consent was obtained from individual participants before the commencement of data collection. In addition, respondents were informed of their right to voluntarily participate or withdraw from the study at any stage without adverse consequences. All methods were performed in accordance with the relevant guidelines and regulations.

Results
A total of 271 questionnaires were administered, of which only 220 were correctly completed, returned and subsequently analysed, for a response rate of 81%.
The socio-demographics of the respondents are presented in Table 1. The ages of the respondents ranged from 20 to above 75 years, with a mean age of 53.3 ± 10.1. Most (164, 74.5%) of the TBAs were females. With regard to years of experience, the majority (154, 70%) had more than 20 years of practice, and few (7.3%) had less than 10 years of practice. The educational status of the respondents showed that those with secondary education were the most represented (103, 46.8%), while few reported no education (17, 7.7% Table 2b shows the preventive practices of TBAs towards postpartum haemorrhage of mothers, which included taking recommended medications and physical practices before and after delivery of the baby. Regarding medications, the TBAs largely reported not administering the following medications: I. M Ergometrine 0.2 mg (2 cc) immediately after delivery, 178 (80.9%); I.M. M oxytocin 10 i.u., 154 (70%); and misoprostol 600 mcg by mouth before delivery, 181 (82.3%). Conversely, the results showed mixed outcomes on the performance of physical practices. Specifically, 183 (83.2%) indicated delayed clamping or cutting of the baby's cord after delivery, 171 (77.7%) indicated stimulating the woman's nipples to prevent PPH, 65 (29.5%) delivered the placenta by cord-controlled traction, 39 (17.7%) performed uterine massage after delivery of the placenta, and 179 (81.4%) encouraged mothers to regularly empty their bladders. On average, approximately 51.6% of the TBAs had at least one preventive practice for postpartum haemorrhage. Figure 3 shows that a high proportion (141, 64.1%) of the respondents had inadequate preventive practices, while 79 (35.9%) had adequate preventive practices.
As depicted in Fig. 4, a huge majority (199, 90.5%) of the TBAs had previously managed postpartum haemorrhage, while 21 (9.5%) had not managed it previously. Table 3 shows the management practices adopted by the TBA centres towards women with postpartum haemorrhage. TBA centres reported always practising the following: the use of appropriate sterile instruments, 195 (98%); the use of herbs or flowers for controlling bleeding, 65 (32.7%); uterine massage, 65 (32.7%); giving mothers concoctions, 62 (31.2%); use of anointing and other forms  Figure 5 shows that of the 199 respondents who had previously managed postpartum haemorrhage, a high proportion (138, 69.3%) of the respondents had poor management practices, while 61 (30.7%) had good management practices with regard to PPH. As displayed in Fig. 6, a high proportion (94, 42.7%) of the TBAs did not know whether there were existing protocols for the management of PPH. Eighty-five (38.6%) knew of existing protocols, while 41 (18.6%) said that no protocols for PPH management existed. The most cited existing protocols were manuals from schools and conferences, followed by the use of incantation and herbs.

Association between TBAs' sociodemographic characteristics and management practices.
The results revealed that the TBA type (P = 0.031), gender (P = 0.029), educational level (P = 0.035) and average number of births per month (P = 0.001) showed significant associations with TBAs' management practices (Table 4).

Association between TBAs' sociodemographic characteristics and preventive practices.
The results revealed that the TBA type (P < 0.001), average number of births per month (P = 0.003) and receipt of formal training (P = 0.005) showed a significant association with TBAs' preventive practices (Table 5).   Table 6, the logistic regression model was used to determine the factors that influenced the preventive and management practices of the TBAs. The significant factors in the bivariate analysis were incorporated into the regression model. TBAs' preventive practices towards PPH were influenced by the TBA type (OR: 4.23; 95% CI: 1.64-10.90); clerical TBAs were 4 times more likely to have inadequate preventive practices than herbalist TBAs. The average number of monthly births (fewer than 10 births) was a protective predictor (OR: 0.17; 95% CI 0.60-0.45); the more (fewer than 10) monthly average births there were, the less likely (83%) an individual was to have inadequate preventive practices compared to having 10 or more monthly average births. Similarly, the TBAs' management practices were also influenced by the TBA type (OR: 4.42; 95% CI: 2.03-9.61); the cleric TBAs were 4 times more likely to have good management practices than the herbalist TBAs. TBAs' educational level and average number of monthly births were less likely predictors.

Discussion
Postpartum haemorrhage remains a major cause of maternal mortality 1 . However, the reduction of maternal mortality is part of the Sustainable Development Goals, Goal 3 target, which is to reduce global maternal mortality to less than 70 per 100,000 live births per year by 2030 25 .  www.nature.com/scientificreports/ In the present study, the majority of the TBAs were in the age group of 40-59 years, with a mean age of 53.3 ± 10.1 years, and most of them were female. Approximately half the respondents had secondary education, with the majority having more than 20 years of experience' . They were largely of the Yoruba tribe, while the TBA type was largely clerics and a few herbalists. These findings were in consonance with a similar study conducted in other parts of Nigeria 21 .
Knowledge refers to the awareness or understanding of a subject matter (person or thing), such as objects (acquaintance knowledge), facts (propositional knowledge) or skills (procedural knowledge) 26 . The present study revealed that most (76.4%) of the TBAs had good knowledge of the causes and warning signs of postpartum haemorrhage, while a few (23.6%) of them had poor knowledge. This is similar to a study among nurse-midwives in Bayelsa State, Nigeria, which equally showed a high level of knowledge about PPH among nurse-midwives 11,27 and similar knowledge among nurse-midwives of the prevention and management of PPH in Khartoum, Sudan 12,28 . The high level of knowledge of the respondents may be attributed to their formal education and previous training. However, in contrast to our study, a study in the Gambia revealed a huge gap in the knowledge of TBAs regarding the prevention, recognition and management of postpartum haemorrhage; TBAs did not know the causes of excessive blood loss 13,29 . In addition, a study in Tanzania revealed a low level of knowledge of danger signs for complications of pregnancy, such as PPH 15,30 . Furthermore, in an interventional study in Ogbomoso Oyo State Nigeria, the preintervention knowledge level among TBAs for the identification of PPH was low (7.2%) 16,31 .
Active management of the third stage of labour (AMSTL) is a common method adopted by skilled providers to reduce the incidence of PPH in clinical practice. If used at every birth, AMSTL would reduce PPH by 30-50% 32 . AMSTL involves the administration of a prophylactic, clamping and cutting of the umbilical cord and controlled-cord traction as interventions during the baby's birth 32,33 . The present study revealed that a high proportion (69.3%) of the respondents who had previously managed PPH had poor management practices, while 30.7% had good management practices. The common management skills for the prevention and control of PPH employed by the respondents included uterine massage, the use of appropriate sterile instruments, urinary catheters, the use of herbs or flowers for the control of bleeding, the use of herbs for the stimulation of contractions, and giving mothers concoctions. However, the following were rarely practised by the respondents: the use of oxytocin, the use of misoprostol, fluid augmentation and blood transfusion. This report negated the findings of Babatunde et al. 21 in which TBAs reported the early use of cord clamping after 3 min, emptying of the bladder during the third stage of labour, placing women in the Trendeleburg position and the use of uterotonics. The WHO revealed that one way that unskilled birth attendants (TBAs) could help to reduce PPH is through the use of oral intervention with misoprostol and oxytocin, which were included in the WHO's Essential Medicines List. The WHO now supports the administration of misoprostol by nonskilled birth attendants at home deliveries 34 .
Similarly, in the bivariate analysis, four factors were associated with good management practices, including the TBA type, gender, education level and the average number of births per month, which all showed statistically significant associations with TBA management practices (P < 0.05). However, in the binary logistic regression, the TBA type was the only statistically significant predictor of good management practice towards PPH. A qualitative study by Ononge et al. in rural Uganda revealed poor management of PPH by TBAs, with some believing that vaginal bleeding after childbirth was a normal and cleansing process and practising the use of herbs. However, it was reported that some referred to the health facility or invited health workers to assist them 17,35 . Similarly, a study by Konje et al. in Tanzania reported the management of PPH by TBAs using various methods, including the use of herbal medicines and abdominal massage, with the majority referring their clients to a nearby health facility 15,36 . These studies were similar to the present study because they both conducted research in developing countries (resource-poor settings) that retain several traditional beliefs, including the preferred use of TBAs, and many misconceptions.
This study reveals that a high proportion (64.1%) of the respondents had inadequate preventive practices, while few (35.9%) had adequate preventive practices. In the bivariate analysis, three factors were associated  Policy implementation and the way forward. A healthy nation is a prosperous nation. As it is sometimes claimed that "health is money", the health sector in Nigeria is one of the institutions that deserves strong governance and development. The Nigerian health industry is divided into two distinct health systems: the traditional therapeutic system of treatment and the modernized system in the West. Although customs are not recognized by the government, studies have revealed that they enjoy widespread support in society 22 . Research has also shown that TBAs were in existence prior to the development of modern medicine, and the current study To reduce maternal mortality in Nigeria, it is imperative to increase women's access to trained delivery attendants. Training TBAs to manage PPH, the main cause of maternal mortality, especially with the use of oral misoprostol to supplement their local treatment techniques as in other developing countries, may help to reduce maternal death in developing nations such as Nigeria, where very few births are attended by SBAs and traditional health care is valued. This will go a long way towards achieving both quantitative and quality health care in Nigeria and in Osun State specifically and hence excellent governance and development in the health sector.

Conclusion
In this study, we found that most TBAs are knowledgeable about the cause and warning signs of PPH in pregnant women. However, there are inadequate preventive practices and poor management practices despite a high level of knowledge. We also found that the predictors of management and preventive practices for PPH were the type of TBA and the type of training received, while educational level and the average number of monthly births were less likely predictors. Thus, it is recommended that supportive supervision, constant monitoring and evaluation www.nature.com/scientificreports/ with continuous health education and training can maximize the gains of TBAs. Targeted intervention using identified factors will also increase the effectiveness of TBAs.

Data availability
All data generated or analysed during this study are included in this published article [and its supplementary information files].